I wonder sometimes, are physicians valued professionals or merely problems to be solved? Are we skilled clinicians vital to the well-being of our patients or are we just assets to be managed? This occurs to me as I see the overgrowth of people with clipboards, people with undue authority over our practices, people trained in business but not in the science or art of medicine.
I see the struggles of good clinicians beset by administrators (who are beset by rules and threats from federal and state overseers as well as groups like the Joint Commission). Granted, a few docs will always need redirection, but we should be doing it instead of leaving it to those who really don't understand. The things done in the name of corporate compliance or patient satisfaction or any of the dozens of other new catchphrases, however, are done in a way that sees physicians as wayward children, or worse, as felons looking to commit crimes. We are often treated as if we are on preemptive parole.
The problems sometimes stem from patient complaints and customer satisfaction. I've said it before: the problem is that the customer satisfaction model does not move easily from Retail America to Medical America. Our “customer” is often unreasonable, rude, profane, or threatening, and he frequently has inappropriate expectations. And this is transformed into a scenario in which the physician (or nurse) who cared for the customer must have been the problem. It is interesting to see clipboarded staff desperately trying to make excuses for the drunk, addicted, or rude people who slow down care and make life unpleasant for the medical and nursing “commodities.” They always seem a little confused when we explain that these customers never pay anything to the hospital. They have one paradigm and shifting from it is simply impossible (unless the entire industry shifts).
I even saw this at work after a mentally ill patient nearly killed a nurse and injured several others. The meetings that followed were sometimes comical, as administrators sat wringing their hands over whether we needed cameras and more security and whether police officers should be allowed to have weapons in the ED. (We can't have a dangerous customer being shot, it appears.)
Physicians aren't just “problematic” and “disposable;” we are now viewed with suspicion. The amount of oversight and regulation of our profession is staggering. Hospitals have multiple employees and committees to track credentialing, complaints, compliance with regulations, and quality of care. They are forever keeping charts, logging the time till the patient was seen, till he was discharged, till the CT scan was done or read, till the ECG was ordered and interpreted. They bring us forms and show us files and remind us over and over that we are under scrutiny. They check the charts and take us aside: “I need to discuss this with you,” sometimes in the midst of our busy shifts. I realize that some of this is driven by the Joint Commission or CMS, but that doesn't mean hospital administrations shouldn't make compliance as easy as possible. And it doesn't mean that they can't give feedback to the higher powers about the utility or difficulty of these measures.
Doctors have enormous oversight. We have assorted board exams in medical school and residency and then specialty boards that reasonably ensure our competence. We have background checks, state licenses, and narcotics permits, for which we need more background checks and fingerprinting. We need references and even more background checks when applying to new hospitals or states. We have to demonstrate that we have been continuously employed and give the dates and contacts. They tsk, tsk over even one lawsuit, even if it was years ago, as if any error were an indicator of a character flaw. It may seem benign to those outside of medicine, but it feels onerous from where I sit. It feels as if I've done something bad and need to be watched by teams of trustworthy, diligent managers.
But what bad thing have I, have you, done? In emergency medicine especially, we have worked long and hard to be trained, and we have spent days, evenings, and nights frequently treating the poor and destitute, the drunk and addicted, the gravely injured and ill. Much of our care has been free. We have been available holidays and weekends, and we have done it while trying to please the customers and respect our managers.
Our efforts, our struggles, our lives and deaths, our days and nights sometimes make it a little difficult to be endlessly monitored and judged by those unavailable after hours, by those whose days are meeting after meeting punctuated by lunch and paperwork, and upon whom no one is imposing rules that say, “You had 10 minutes to finish that form. You went beyond that, and I'm going to have to start documenting your progress. If you can't do better, we may need to consider hiring someone else.”
Our collectively well-demonstrated dedication to emergency medicine and medicine in general makes it galling and demoralizing to know that from every angle, from every organization, at all hours of the day and night, we receive more oversight than the average criminal. In fact, I have cared for patients injured while driving under the influence, only to find that they had previous convictions pled down to first offense. For us, it feels as if there is no plea bargain, only another file kept in another office.
Increasingly, as in much of regulation-driven America, our crimes, our errors, will seem small to us but enormous to the “machine” that is the modern hospital. These will involve the things already mentioned: time to EKG, time to PCI, time to CT, time to documentation. They will be issues of documentation and screening with time limits attached. There will be issues of patient satisfaction tied to reimbursement. They will all happen in what will continue to be the endlessly chaotic world of the ED, where there is never a limit on who can come in or on what we are asked to do for patients, consultants, and administrators.
I understand. There are rules and regulations, and someone has to implement them. But there are too many, and clinicians need support more than increased distrust and oversight. I get it; there are bad doctors. But most are good and need to be valued as such.
I don't want to spend my career feeling like a criminal or like a problem to be managed. I want to spend it doing the job I love and do so well, which is caring for the sick and injured.
Dear administrators, politicians, and regulators: In the words of my surgery resident during medical school: “Help me; don't hurt me.”
© 2014 by Lippincott Williams & Wilkins
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